Diagnosis of Fibromyalgia Syndrome (FMS)



Prevalence 4% - 7x in Females Global problem. PMR is very rare under the age of 50.Practically, most useful to consider FMS to be a maladaptive pain response leading to bodily distress.Associated with Chronic Fatigue Syndrome, which is an important differential.Diagnosis of Fibromyalgia Syndrome (FMS)No current diagnostic test for FMSMultiple somatic symptoms + classically described tender points.11 out of 18 well defined tender points. American College Rheumatology guidelines (2010) says you do NOT need to do a detailed assessment of tender points greater emphasis on the patient’s pain, its severity and somatic symptoms experienced (see table below)If you suspect FMS, it is worth going back through the patient’s notes depression, anxiety, eating disorders and childhood abuse are all significantly associated with FMS.Three Top tips!Trust your clinical instinct. 2. Look for cues of bodily distress. 3. Use chart to confirm diagnosis 090805For FMS, all of 1, 2 and 3 must be satisfied.00For FMS, all of 1, 2 and 3 must be satisfied.WPI ≥7 and SS ≥5 or WPI 3-6 and SS≥9Symptoms have been present for at least three monthsThere is no alternative explanation for the painDifferentialsThe following conditions can also cause widespread musculoskeletal pain:Inflammatory arthritis (including RA and spondyloarthropathies)Polymyalgia rheumaticaPolymyositis/dermatomyositisChronic Fatigue SyndromeVit D deficiencyStatin side effects Hypo/hyperthyroidismMultiple sclerosisHypermobility syndromes (please see the diagram opposite for more information on diagnosing this condition, which often coexists with FMS)MalignancyVasculitides, Neuropathies, Osteomalacia-----------------------------------------------------------------------------------------------------------------------------------------------------------------Hypermobility is common, easy to diagnose clinically but also easy to miss if you don’t think of it. It is actually a risk factor for FMS, so a patient may have both conditions. Thyroid disease and statin-related pain are quite common. Mild vitamin D deficiency is very common and in fact 16% of the UK population will have significant vitamin D deficiency in the winter months. In patients presenting principally with fatigue, exclude restless leg syndrome or sleep apnoea. Most of the other differentials are rare as new presentations in primary care. Beighton's modification of the Carter and Wilkinson scoring system for Hypermobility Syndrome3676650991870Give yourself 1 point for each of the manoeuvres you can do, up to a maximum of 9 pointsInterpretationScore of 4 or more with arthralgia for >3m = hypermobility syndrome400000Give yourself 1 point for each of the manoeuvres you can do, up to a maximum of 9 pointsInterpretationScore of 4 or more with arthralgia for >3m = hypermobility syndromeInvestigationsFBC, ESR, CRPTSH (thyroid dysfunction)CK (creatine kinase) – polymyositis/dermatomyositisCalcium, 25 hydroxyvitamin D (osteomalacia, vit D def)Alkaline phosphataseBlood glucose (or HbA1c)Urinalysis for protein, blood and glucoseNote: ANA and Rheumatoid Factor/anti-CCP should only be done if there are specific pointers in the history or examination which raise the suspicion of an inflammatory arthritis or connective tissue disease.Management starts with ExplanationKnowing how to discuss FMS with patients is a key skill in determining how patients will engage. Explanations are key. Patients with FMS just want to be believed, diagnosed correctly, understood and to have a confident, positive and patient-centred management plan.Pejorative terms do not help: ‘it’s all in your mind’ – number needed to offend (NNO) = 2Pathophysiological explanation incorporating the nervous system NNO =9Explanation must remove blame, not denigrate, incorporate psychological and the biological, enable negotiation of a constructive management plan. To do this –Explore ICE & the psycho-social (work, family life, dynamics, stresses).Look at joints to ensure joints don’t look inflamed nor synovium thickening.Examine – make a fist, squeeze, make a prayer, dorsum of hand to dorsum of other handFeedback the blood results done. Explain FMS is common. Find out what they know about it – start with their starting point.“In FMS it seems like your body thermostat for pain is wrongly set, so that pain and other sensations are amplified. Why this happens nobody knows – there have been theories, but not single cause has been found – probably because it’s not because of just one thing. We know how bad the pain can be and we know it’s not in your mind. It’s not psychological. The body, the brain, the spine, the nerve endings as well as various hormones and chemical all work together. In FMS there is disturbance in the general balance of these. To restore the balance, the first think we need to do is to ensure you understand quite a bit about FMS and keep a positive attitude otherwise it might not get better.”Management after ExplanationNo need to see a specialist – most of these are managed in GP. Excellent leaflet from FMS on Arthritis UK – and ask them to look at the excellent website on it. Try and encourage to get back to work.Amitriptyline? – works about 2w time. Warn: dry mouth, blurred vision - usually short lived.Review 4w.What works?RecommendationStronger evidenceWeaker evidenceNon-pharmacologicalHeated pool treatment (balneotherapy)Relaxation, rehabilitation, physiotherapy and psychological supportIndividually tailored exercise programme, including aerobic exercise and strength trainingCBTPharmacologicalTramadol for pain managementAmitriptyline (TCAD)Fluoxetine (SSRI)Duloxetine (SNRI)These drugs are used to reduce pain and often improve functionTramadol, Pramipexole and pregabalin reduce painSimple analgesics and weak opioidsNote: no good evidence for analgesic effect of NSAIDS in FMS! So don’t bother using it. ................
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